Presurgical and Postsurgical MRI Evaluation of Osteochondral Lesions of the Foot and Ankle: A Primer.

The gold standard diagnostic imaging tool for ankle OCLs is magnetic resonance imaging, which allows precise evaluation of the articular cartilage and assessment of the surrounding soft tissue structures. Post-operative morphologic MRI assessment via MOCART scores provide semi-quantitative analysis of the repair tissue, but mixed evidence exists regarding its association with post-operative outcomes. Post-operative biochemical MRIs allow assessment of the collagen network of the articular cartilage via T2-mapping and T2∗ mapping, and assessment of the articular glycosaminoglycan content via delayed gadolinium-enhanced MRI of cartilage (dGEMRIC), T1rho mapping and sodium imaging.

Tumor location and type affect local recurrence and joint damage in tenosynovial giant cell tumor: a multi-center study.

Osteochondral destruction and a high recurrence rate after surgery are major concerns that make difficult the treatment course of tenosynovial giant cell tumor. The aims of this study were to elucidate rates of postoperative local recurrence and osteochondral destruction, as correlated with various demographic factors. Eighty surgically treated patients with intra-articular tumors (knee: 49, ankle and foot: 12, hip: 10, others: 9) were included in this study. Factors including age, disease type (diffuse/localized), location, existence of osteochondral destruction were correlated with local recurrence or development/progression of osteochondral destruction. The 5-year local recurrence free survival rate was 71.4%. Diffuse type (n = 59, localized: n = 21) (P = 0.023) and knee location (P = 0.002) were independent risk factors for local recurrence. Diffuse type (P = 0.009) was a significant risk factor, and knee location (P = 0.001) was a negative factor for osteochondral destruction at the initial examination. Progression of osteochondral destruction was observed more often in cases with local recurrence (P = 0.040) and findings of osteochondral destruction at the initial examination (P = 0.029). Diffuse type is a factor that should be noted for both local recurrence and osteochondral destruction, while local recurrence occurs but osteochondral destruction is less observed in the knee.

Retrospective evaluation of outcomes of bone peg fixation for osteochondral lesion of the talus.

AIMS: The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications. METHODS: Between September 2014 and July 2017, 25 patients with symptomatic osteochondritis of the talus and an osteochondral fragment, who were treated using bone peg fixation, were analyzed retrospectively. All were available for complete follow-up at a mean 22 of months (12 to 35). There were 15 males and ten females with a mean age of 19.6 years (11 to 34). The clinical results were evaluated using a visual analogue scale (VAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score preoperatively and at the final follow-up. The radiological results were evaluated using classification described by Hepple et al based on the MRI findings, the location of the lesion, the size of the osteochondral fragment, and the postoperative healing of the lesion. RESULTS: The mean VAS and AOFAS score improved significantly from 6.3 (4 to 8) and 70.6 (44 to 78) preoperatively to 1.6 (0 to 5) and 91.1 (77 to 100) at the final follow-up, respectively (p < 0.001). The classification on MRI was stage 2a in nine patients, stage 3 in 14, and stage 4 in two. The lesion was located on the posteromedial aspect of the dome of the talus in 19 patients, the anterolateral aspect in five, and the centrolateral aspect in one. The mean size of the fragment was 11.2 mm (5 to 20) horizontally, 10.4 mm (7 to 18) vertically, and 5.2 mm (3 to 10) deep, respectively. The postoperative healing state was good in 19 patients and fair in six. CONCLUSION: Bone peg fixation for osteochondral lesions of the talus showed satisfactory clinical and radiographic results, without complications. This technique could be a good form of treatment for patients with this condition who have an osteochondral fragment. Cite this article: Bone Joint J 2020;102-B(10):1349-1353.

Metatarsal Head Restoration With Tendon Autograft in Freiberg's Disease: A Case Report.

Freiberg's disease is a form of osteochondrosis of a metatarsal head that often affects the second metatarsophalangeal joint, and that affects females more often than males. Repetitive microtrauma, osteonecrosis, and stress overload are the main factors in its pathophysiology. Surgical intervention is indicated in advanced cases wherein nonoperative treatment has failed. In this report, we describe the case of a young female who had Freiberg's disease localized to the third metatarsal head bilaterally and who was successfully treated with peroneus longus tendon transplantation.

Patellar sleeve avulsion fracture in a patient with Sinding-Larsen-Johansson syndrome: a case report.

BACKGROUND: Patellar sleeve avulsion (PSA) fractures are rare injuries that occur in in skeletally immature patients. Initial diagnosis is key to a successful outcome, as these injuries are easily overlooked on plain radiographs with poor results well documented from delayed management. High index of suspicion from the mechanism of injury, thorough clinical examination and Magnetic Resonance Imaging (MRI) help to avoid misdiagnosis. CASE PRESENTATION: The case of a 12-year-old male athlete with an acute PSA after a conservative treatment of a SLJ syndrome is described. The patient was referred to our clinic due to severe pain and loss of function after performing a high jump. Plain radiographs (X-ray) and MRI confirmed an inferior pole PSA which was fixed with double trans osseous ultra-high strength tapes. At the 3-month follow- up visit the patient was able to ambulate brace free. At 2-years follow up the patient was able to play soccer and ice hockey. To our knowledge, there are no case reports of inferior pole PSA with prior SLJ syndrome described in literature. CONCLUSIONS: Early clinical suspicion and distinguishing this PSA from other enchondral ossification disorders around the knee is critical to avoid misdiagnosis. Whether SLJ syndrome increases the risk of sustaining a PSA is still not clear. Trans osseous fixation with suture tapes leads to good functional results in a young athlete with inferior pole PSA.

A comparison between arthroscopic and open surgery for treatment outcomes of chronic lateral ankle instability accompanied by osteochondral lesions of the talus.

BACKGROUND: This study aimed to examine the efficacy and safety of the arthroscopic treatment of osteochondral lesion of talus (OLT) and lateral ankle instability. It was hypothesized that the outcome of all-arthroscopic surgery was no worse than that of the combined open and arthroscopic surgery for treating chronic lateral ankle instability accompanied by OLT. METHODS: The patients diagnosed of chronic lateral ankle instability accompanied by OLT, who were surgically treated between May 2015 and May2017, were targeted for inclusion. Specifically, patients who received the arthroscopic treatment of OLT and lateral ankle instability were enrolled in the all-arthroscopic group, while patients who received the arthroscopic treatment of OLT and open lateral ankle stabilization were enrolled in the combined open and arthroscopic group. All the patients were followed up in terms of the Karlsson Ankle Functional Score, visual analog scale (VAS) score, Tegner activity score, and American Orthopaedic Foot & Ankle Society (AOFAS) score. Meanwhile, the satisfaction and complication rates were evaluated and compared. RESULTS: This retrospective study included a total of 67 patients, including 32 patients in the all-arthroscopic group and 35 patients in the combined group. At a minimum of 24-month follow-up, the functional outcomes were significantly improved in both groups in relation to the preoperative condition. However, the two groups did not differ significantly from each other in terms of the Karlsson score (83.1 ± 8.2 vs 81.7 ± 9.1; P = 0.89), the VAS score (1.8 ± 1.6 vs 2.1 ± 1.7; P = 0.73), the Tegner score (5.5 ± 2.3 vs 5.0 ± 2.1; P = 0.72), and the AOFAS score (87.7 ± 7.6 vs 86.9 ± 7.3; P = 0.77). In addition, the satisfaction and complication rates exhibited no significant differences between the two groups. CONCLUSION: In comparison with the open lateral ankle stabilization and arthroscopic treatment of OLT, the all-arthroscopic procedure showed no difference in clinical outcomes at a minimum of 24-month follow-up. Despite the benefits of minimally invasive arthroscopic procedure combined with a relatively aggressive postoperative rehabilitation protocol, the clinical outcomes for patients with chronic lateral ankle instability accompanied by OLT did not yield significant improvement. TRIAL REGISTRATION: The present study was carried out with the approval issued by the Institutional Review Board of Xiangya Hospital (no. 202002010).

Imaging the Pediatric Athlete: Acute and Stress Skeletal Injuries.

Sports-related traumatic injuries in children have increased in tandem with participation in higher level activities. The developing musculoskeletal structures in children are susceptible to unique injuries that vary with location and the stage of skeletal maturation. The imaging evaluation of sports injuries in children presents several unique challenges. The purpose of this article is to educate the reader on injuries unique to the skeletally immature athlete with focus on their imaging evaluation and diagnosis.

More than 40 years' follow-up of an unconstrained metal lunate replacement for the treatment of Kienböck's disease.

Kienböck's disease is characterised by avascular necrosis of the lunate bone, and over the years it has been a challenging disease to manage, with differing opinions on the best intervention. We present an interesting case of a metallic unconstrained lunate replacement that is still functioning well in a patient 40 years after surgery. This case report represents the longest follow-up of any such prosthesis.

Pediatric Osteochondral Lesions.

Osteochondral lesions are common in children and may arise from a variety of etiologies. Although they most frequently occur in the knee, other joints may be involved including the ankle and elbow. We describe the typical imaging appearance of osteochondral lesions with a focus on radiographs and magnetic resonance imaging. Assessment of the stability of these lesions is of paramount importance in directing management. As such, we describe staging schemes as well as imaging features differentiating stable from unstable lesions. Finally, we briefly discuss management strategies as they correlate to imaging findings.

Clinical and MRI Outcomes After Surgical Treatment of Osteochondral Lesions of the Talus in Skeletally Immature Children.

BACKGROUND: The literature on the osteochondral lesion of the talus (OLT) in skeletally immature children is scarce and little is known about the clinical outcomes and the radiologic appearance of these lesions after surgical treatment. The aim of this study was to assess mid-term clinical and magnetic resonance imaging (MRI) outcomes after arthroscopic microfracture (AM) of OLT in skeletally immature children. METHODS: Thirteen patients with OLT treated by AM before skeletal maturity were included in the study. The Berndt and Harty outcome question, the Single Assessment Numeric Evaluation question, and the Martin questionnaire were used to obtain patients' subjective satisfaction with their operated ankle. Functional outcomes preoperatively and postoperatively were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score. MRI scans were performed postoperatively using a magnetic resonance observation of cartilage repair tissue (MOCART) scoring system for 11 ankles. RESULTS: The median age was 15 years (range, 13 to 16 y) and the median follow-up period was 5.6 years (range, 3.8 to 13.6 y). According to the Berndt and Harty outcome question, good clinical results were reported in 10 (76.9%) and fair in 3 (23.1%) patients. The postoperative AOFAS score was significantly improved when compared with the preoperative AOFAS score, with a mean increase of 35 points (P<0.001). The overall MOCART score was 65 (range, 10 to 75). MRI variables of the MOCART scoring system showed no association with clinical outcomes. CONCLUSIONS: AM seems to be an effective surgical method for the treatment of OLT in skeletally immature children. LEVEL OF EVIDENCE: Level IV-therapeutic studies, case series.

Single-Step Arthroscopic Repair With Cell-Free Polymer-Based Scaffold in Osteochondral Lesions of the Talus: Clinical and Radiological Results.

PURPOSE: To report the clinical and radiological results of patients with talar osteochondral lesions who were treated by microfracture and cell-free scaffold implantation in a single-step arthroscopic surgery. METHODS: Forty patients, treated with a single-step arthroscopic surgery, were evaluated in this single-center-based retrospective study. Patients with degenerative arthritis (n = 1), history of ankle fracture (n = 1), kissing lesions (n = 1), lower extremity deformity (n = 1), and lesions <1.5 cm2 (n = 4) were excluded. Oversized (>10 mm depth) bone cysts were additionally treated with bone graft. Patients were evaluated clinically, using the American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score. Radiological assessment was performed with magnetic resonance imaging, using the magnetic resonance observation of cartilage repair tissue (MOCART) score. RESULTS: Thirty-two patients with a mean age of 38 ± 12 years were evaluated. The mean defect size was 2.5 ± 0.8 cm2 and the mean defect volume was 2.4 ± 1.9 cm3. The mean preoperative AOFAS score was 52.8 ± 13.9 and increased to 87.1 ± 11.1 postoperatively at the mean follow-up of 33.8 ± 14.0 months (P = .0001). A total of 84.4% of patients had good to excellent clinical scores. Clinical scores had no significant relation with age, lesion size, depth, or body mass index. The mean MOCART score was 64.2 ± 12.0. There was no significant correlation between the total MOCART and AOFAS scores (P = .123). A significant relation was found between the defect filling (the subgroup of the MOCART score) and the clinical outcomes (P = .0001, rho = 0.731). CONCLUSIONS: The arthroscopic scaffold implantation technique is a single-step, safe, and effective method for the treatment of talar osteochondral lesions with satisfactory clinical and radiological outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Iselin's Disease: A Systematic Review.

Iselin's disease was first described in 1912. It is a condition affecting the tuberosity of the base of the fifth metatarsal. It has been described as a traction apophysitis predominately affecting adolescents, in particular those who partake in regular sporting activity. The condition is rarely reported and likely to remain undiagnosed, possibly mistaken for a fracture. The present report reviewed the available published data to highlight this condition as a differential diagnosis in patients with fifth metatarsal pain. Investigations, treatments and outcomes into this condition are described, to support the management and diagnosis of this condition.

Associations of three-dimensional T1 rho MR mapping and three-dimensional T2 mapping with macroscopic and histologic grading as a biomarker for early articular degeneration of knee cartilage.

T1 rho and T2 mapping are magnetic resonance imaging (MRI) techniques to detect early degenerative changes in cartilage. Recent advancements have enabled 3D acquisition for both techniques. The objective of the present study was to examine the correlation of 3D T1 rho and 3D T2 mapping with macroscopic and histological characteristics of knee cartilage. Twenty-one patients who underwent total knee arthroplasty due to osteoarthritis with involvement of the medial compartment but with minimum involvement of the lateral compartment were enrolled. Prior to surgery, five series of MRI were acquired with a 3-T scanner. 3D T1 rho/T2 analyses were performed following determination of regions to be assessed using in-house software that incorporated three series of MRI acquisitions data (3D-MERGE, 3D-SPGR, and 3D-CUBE). During surgery, the cartilage of the lateral compartment was macroscopically assessed with the International Cartilage Research Society (ICRS) articular classification system. The extracted specimens were histologically assessed using the OARSI histology score. Three regions of interest (ROI) were assessed for each slice (two slices per knee): the central lateral femoral condyle (cLFC), the posterior portion of the lateral femoral condyle (pLFC), and the lateral tibia plateau (LTP). For each ROI, the mean T1 rho and T2 relaxation time, the ICRS grade, and the OARSI score were compared. Neither the T1 rho nor the T2 reflected the macroscopic grading. The T1 rho could discriminate between histological grades 1 and 2. However, the T2 could not. The T1 rho relaxation time was higher in the pLFC than in the cLFC even in the same grade. Compared to T2 mapping, T1 rho mapping may have an advantage in differentiating grades I and II cartilage degeneration on OARSI histological grading system.

Juvenile Particulate Osteochondral Allograft for Treatment of Osteochondral Lesions of the Talus: Detection of Altered Repair Tissue Biochemical Composition Using 7 Tesla MRI and T2 Mapping.

During the previous 2 decades, numerous surgical procedures have become available to treat osteochondral lesions of the talus. The objective of the present study was to use 7 Tesla (7T) magnetic resonance imaging (MRI) to quantify and compare T2 values (a marker of collagen architecture) of native tibiotalar cartilage and cartilage repair tissue in patients treated with a juvenile particulate allograft for osteochondral lesions of the talus. The institutional review board approved the present study, and all subjects provided written informed consent. We scanned the ankles of 7 cartilage repair patients using a 7T MRI scanner with a multi-echo spin-echo sequence to measure the cartilage T2 values. We assessed the cartilage T2 values in the talar repair tissue, adjacent native talar cartilage, and overlying tibial cartilage. We compared the differences between groups using the paired t test. The talar cartilage repair tissue demonstrated greater mean T2 relaxation times compared with the native adjacent talar cartilage (64.88 ± 12.23 ms versus 49.56 ± 7.82 ms; p = .043). The tibial cartilage regions overlying these talar cartilage regions demonstrated a trend toward greater T2 relaxation times (77.00 ± 31.29 ms versus 59.52 ± 7.89 ms; p = .067). 7T MRI can detect differences in T2 values in cartilage repair tissue compared with native cartilage and could be useful for monitoring the status of cartilage health after surgical intervention.

Arthroscopic treatment of painful Sinding-Larsen-Johansson syndrome in a professional handball player.

Sinding-Larsen-Johansson (SLJ) syndrome is a type of osteochondrosis of the distal pole of the patella most often caused by repeated microtrauma. Here, we describe the case of a professional athlete with painful SLJ syndrome treated arthroscopically. A 29-year-old male professional handball player presented with anterior knee pain that persisted after 4 months of an eccentric rehabilitation protocol and platelet-rich plasma injections. Despite this conservative treatment, the patient could not participate in his sport. The SLJ lesion was excised arthroscopically, which led to complete disappearance of symptoms and return to competitive sports after 5 months.

Is there a relationship between talar osteochondral lesions and foot angles?

PURPOSE: We aimed to evaluate the relationship between talar osteochondral defects (OCDs) and foot angles in this study. MATERIALS AND METHODS: We performed a retrospective study that included 25 patients with talar OCD and 29 patients without OCD who underwent magnetic resonance imaging in our department between September 2013 and January 2015. We retrospectively measured the foot angles (Bohler's angle, lateral talocalcaneal angle and calcaneal inclination angle) on ankle radiographs in both groups. RESULTS: Bohler's angle showed no significant differences between the patients (range 20.50°-48.10°, mean 33.40° ± 6.09°) and the control group (range18.80°-42.40°, mean 31.95° ± 4.21°) (p = 0.397). Calcaneal inclination angle showed no significant differences between the patients (range 3°-29.2°, mean 20.55° ± 6.73°) and the control group (range 10.20°-29.80° mean 20.47° ± 4.21°) (p = 0.956). However, talocalcaneal angle was significantly higher in the patients (range 27.80°-44.80°, median 39.50° ± 6.18°) compared with the control group (range 22.60°-40.50°, median 34.10° ± 4.26°) (p = 0.032). CONCLUSION: There is an association between lateral talocalcaneal angle and non-traumatic talar OCD.

Long-term Follow-up of Dorsal Wedge Osteotomy for Pediatric Freiberg Disease.

BACKGROUND: Treatment for Freiberg disease has been largely conservative despite availability of various operative options for severe or refractory cases. The aim of this study was to evaluate the long-term results of pediatric patients with symptomatic Freiberg disease treated with intra-articular dorsal wedge osteotomy. METHODS: Pediatric patients treated for Freiberg disease with surgery between January 1982 and 1999 were identified and selected for long-term clinical evaluation. Patients were evaluated regarding operative satisfaction and clinical outcome, performed according to the American Orthopaedic Foot & Ankle Society (AOFAS) lesser toe metatarsophalangeal-interphalangeal scale and range of motion (ROM) of metatarsophalangeal (MTP) joint. Patients had radiographic assessment of degenerative joint status with anteroposterior and oblique foot x-ray. Twenty patients (18 female, 2 male; mean age 15.2 years; range 12-17 years) were identified. The mean follow-up period was 23.4 (range 15-32) years. RESULTS: The clinical outcomes of our patients were classified as excellent in 16 (80%) and good in 4 (20%). The AOFAS mean score was 96.8 (range 91-100) points at the last clinical appointment. A negative correlation between AOFAS score and time of follow-up (r's = -0.61, P < .001) was found. Also, a strong negative correlation was found between Smillie classification and AOFAS final score (r's = -0.88, P < .001). CONCLUSION: The patients were very satisfied with pain and quality of life at a mean follow-up time of 23.4 years. To our knowledge, this is the first long-term follow-up report supporting the procedure described by Gauthier and Elbaz as a good option for operative treatment of Freiberg disease. LEVEL OF EVIDENCE: Level IV, retrospective case series.